- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,510.34 / $1,510.34 / $2,806.78
| Facility | | $1,510.34 | $1,510.34 | $2,806.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,466.78 / $1,597.48
| Professional | | $1,452.25 | $1,466.78 | $1,597.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Facility | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $2,700.00
| Professional | | $1,452.25 | $1,452.25 | $2,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.64 / $1,452.25 / $1,524.86
| Professional | | $1,379.64 | $1,452.25 | $1,524.86 |